‘It's not what you'd term normal smoking’: a qualitative exploration of language used to describe heated tobacco product use and associated user identity

Abstract Background and aims Tobacco and nicotine marketplaces have diversified over the past decade, including with the introduction of heated tobacco products (HTPs), such as the brand IQOS. HTPs typically heat tobacco to generate an aerosol that is inhaled. HTP nomenclature is lacking, and how HTP users define and identify themselves remains understudied. Research in this area is important because language can construct identity, and identity can shape behaviour. This study aimed to explore users' language choice when describing IQOS use, and how language relates to user identity. Methods Qualitative interviews in London, United Kingdom, with 30 adult current and former IQOS users. Analyses were guided by Iterative Categorization. Results Overall, participants expressed confusion and a lack of suitable terminology for how to describe IQOS use. Verbs such as heating and IQOSing were rarely endorsed. Most often, participants reverted to smoking when describing IQOS use and commonly referred to HEETS (tobacco sticks) as cigarettes. Yet the lack of combustion, electronic device, cleaner experience and perceived reductions in health risks led some to frame IQOS as distinct from smoking. Vaping was generally considered inappropriate for describing IQOS use. Participants also manipulated language to suit their circumstances and manage their identity, whereas some IQOS users embraced the terms smoking and smoker, most were eager to distinguish between using IQOS and being labelled a smoker because of the associated negative connotations and to align with perceptions of IQOS use as a better, less harmful behaviour. Instead, when describing their identity, IQOS users more willingly identified as vapers, or ex‐smokers, or created new identities (e.g. HEET user). Conclusions People who use or have used IQOS (a brand of heated tobacco product) are ambiguous about IQOS terminology. Participants in this study commonly referred to IQOS use as smoking for lack of a more suitable term, but also resisted being labelled as smokers, a choice that may influence smoking cessation. Clear terminology must be used in surveys and by healthcare professionals when asking about cigarette smoking and e‐cigarette and heated tobacco product use.


INTRODUCTION
The tobacco and nicotine marketplace has experienced unprecedented diversification over the past decade [1], including the introduction of heated tobacco products (HTPs) such as glo, Ploom and IQOS [2]. HTPs are electronic devices manufactured by tobacco companies, such as Philip Morris International. HTPs typically heat tobacco to generate an aerosol, and are hence purported to be less harmful than smoking combustible cigarettes. IQOS is especially widespread, being commercialised in 64 markets as of 2020 [3]. In the United Kingdom (UK), IQOS has been marketed since 2016, although current use remains low at <1% and almost entirely among current or former smokers [4].
Language can construct identity, which in turn can shape behaviour [6,7]. For example, smokers who quit but continue to identify as a smoker are at greater risk of relapse [8], whereas those who identify as a non-smoker are more likely to stay quit [9,10]. Some smokers also reject vaping because vaping does not fit within their smoker identity [11]; identity could, therefore, hinder switching to a different nicotine product. It is unclear how HTP users define and identify themselves and how this impacts HTP use and smoking. Understanding HTP user identity and terminology can also inform survey design such as how to refer to HTPs and HTP use.
We, therefore, qualitatively explore the language used to describe use of the leading HTP in the United Kingdom (IQOS) and consider how language relates to user identity.

METHODS
Methods are described in the Appendix S1 and previous publications [12,13]. Briefly, 30 UK residents ages 18+ years that currently/ formerly used IQOS and smoked combustible cigarettes were interviewed between 2018 and 2019 about their experiences using IQOS.
In the first interviews, participants (often unprompted) raised thoughts about how to refer to using IQOS and engaged in detailed discussions about appropriate terminology. Use of language was probed in all subsequent interviews.
Analyses were guided by Iterative Categorization [14,15], a systematic and staged approach to qualitative data analyses. For this paper, we systematically reviewed, inductively consolidated, and reorganised data within the 'language' and 'identity' codes [15]. This included exploring the data for differences by age, gender and smoking and vaping experiences, and considering findings within the broader context and established knowledge. Table 1 shows the sample characteristics. Most currently used IQOS.

FINDINGS
While all but two had tried vaping e-cigarettes, most did not currently vape (n = 26) and/or had unsatisfactory experiences with vaping.
A 'new way' of smoking

Lack of suitable terminology
Overall, when discussing what language best describes the act of using IQOS, participants expressed confusion and reported a lack of suitable terminology. Participants commonly used the brand name IQOS when referencing the device, but tended to shy away from using this when describing use because it sounded pretentious, gimmicky, or was not widely recognised. IQOSing was not considered a useable verb. Similarly, heat-not-burn or heating-not-burning were considered unsuitable because of their long-winded nature, and the verb heating was deemed inappropriate given its alternative contextual use as a source of warmth.
I'm not really sure what to call it … IQOS is not the best term … it's a bit hard to say, IQOS, and you certainly could never say IQOSing … that's way too much of a tongue twister! … It just doesn't trip off your tongue very easily … HEETing sounds a bit weird. (Raj, age 43)

Appraising alternative terminology
Participants, therefore, generally understood their own use of IQOS as smoking and used phrases such as going to smoke when describing their behaviour to others. This was based on their perceptions that the physical act and sensation of using IQOS closely mimics smoking combustible cigarettes: it has the same tobacco taste, provides a similar throat hit, involves the same rituals, has a defined start and end point and produces a smoke-like exhale, albeit less voluminous. Furthermore, smoking was perceived to be a more understandable Not at all 9 Time using tobacco and nicotine products a 1-5 years 9 6-10 years 5

11-20 years 3
More than 20 years 12 a Includes use of other tobacco and nicotine products (e.g. shisha and cigars). One participant did not disclose time since using tobacco and nicotine products, so missing data exist. reference for others, partly out of habit from prior use of combustible  [16].
Limitations include that our sample comprised adults <60 years old who were mainly in professional occupations, unlike typical combustible cigarette smokers in the United Kingdom [13], so our findings may not generalise beyond these groups. Strengths include using multiple recruitment methods to access a sample with diverse experiences and one-to-one in-depth interviews to have detailed conversations on IQOS terminology and identity.